Late last week U.S. Department of Health and Human Services (HHS) indicated they will be permitting states to maintain coverage for autism behavior therapies, such as Applied Behavior Analysis (ABA), as part of their essential health benefits package when provisions of the new federal health care law take effect in 2014.
“HHS has committed to giving states flexibility in determining benefits,” said Lorri Unumb, Esq., vice president for state government affairs. “Entering 2012, 29 states representing 70 percent of the U.S. population have already made that decision and it is to require coverage of autism benefits. Today’s guidance gives states the freedom to maintain the coverage they have designed for their citizens without having to defray costs for ‘excess’ benefits.”
Under the Patient Protection and Affordable Care Act of 2010, the HHS was directed to determine an essential_health_benefits_bulletin package that would be offered in the individual and small group markets, both inside and outside of the Affordable Insurance Exchanges created under the law that begin operation in 2014. HHS, in its decision on Friday, gave the states the flexibility to choose from four types of health plans in establishing a benchmark for what services should be covered.
“Autism Speaks is optimistic this will enable states to continue to provide comprehensive autism therapies, such as ABA, as part of their essential health benefits package,” Unumb said. In the 29 states which have enacted autism insurance reform, Unumb said, most of the four plans would cover behavioral health treatments, such as ABA.
Here in Washington state however the disparity continues despite herculean efforts by advocates, multiple lawsuits testing one of the most comprehensive Mental Health Parity Laws in the nation. As we ring in the new year, thousands of families are cautiously optimistic that Washington State Health Care Purchasing Agencies will catch up to the rest of the nation to provide our children, adolescents and adults with ASD’s basic health care benefits for treatment of autism.
Specialized Behavior therapies (including Applied Behavior Analysis) and neurodevelopmental therapies are “mental health services” designed to treat autism, a DSM (Diagnostic and Statistical Manual of Mental Disorders) category. Under Mental Health Parity, blanket insurance policy exclusion for services, therapies and supplies (as well as unreasonable caps) related to the treatment of autism spectrum disorders violates Mental Health Parity laws.
If your children’s therapies are unreasonably capped or they have no benefits for treatments of autism, WAAA can help. Contact 425.894.7231 or Info@washingtonautismadvocacy.org. Please indicate whether your child is covered through private insurance or medicaid. Washington Autism Alliance & Advocacy is committed to ensure timely access to medical benefits designed to treat autism for all children in Washington.”
Washington’s Network Adequacy Statute and Rules require health plans to ensure that enrollees are entitled to sufficient, timely and appropriate health care services and choice among health care providers (this includes behavior therapies). In articular, the statute requires that “[e]ach carrier must provide for appropriate and timely referral of enrollees to a choice of specialists within the plan if specialty care is warranted(such as Applied Behavior Analysis).
If the type of medical specialist needed for a specific condition is not represented on the specialty panel, enrollees must have access to nonparticipating specialty health care providers.Health carriers are required to maintain adequate networks of providers in order to ensure that health plan enrollees can obtain treatment in their local communities without undue delay, traveling onerous distances or incurring additional out-of-pocket expenses:
An example of “reasonable proximity” is provided in the regulations through the Office of Insurance Commissioner:
“For example, a carrier should not require travel of thirty miles or more when a provider who meets carrier standards is available for inclusion in the network and practices within five miles of enrollees.”
The court is asked not to permit health carriers (Washington State Health Care Authority-HCA) to work around the Court’s Order by imposing a new condition of participating in a research study, for coverage of ABA therapy for autism.
Washington’s Mental Health Parity Act and its Network Adequacy statutes and regulations prohibit HCA’s conditions.
Stephanie Marquis, spokeswoman for the insurance commissioner, has said: “We’re working on a regulation that addresses the issues the courts have ruled on so far that will ensure consumers get the coverage they’re entitled to and insurers understand what they’re required to cover. “The draft language should be ready by the end of the year, she said.
In the meanwhile if any individual with ASD’s has been denied coverage for neuro-developmental therapy (speech, physical therapy, occupational therapy, sensory-motor, neuropsychological evaluation etc.), behavioral therapy (including Applied Behavioral Analysis therapy) or mental health therapy based upon exclusions or limitations in their Washington state insurance policies, please contact WAAA, 425-894-7231 or info@WashingtonAutismAdvocacy.org.
The 6th Annual Autism Law Summit, dedicated to the passage, implementation and enforcement of meaningful autism insurance reform across the nation convened last week at the University of Utah’s Susan J. Quinney School of Law. Lorri Unumb, Autism Speaks VP of State Government Affairs, facilitated the Summit, as she has for the past six years.
The Summit has evolved from an informal gathering of a handful of national advocates, to a capacity-level event from 33 states. Once again, parents, providers, attorneys legislators and regulators, create remarkable momentum in the effort to create a system where individuals diagnosed with an ASD can access coverage for the life-changing treatments they need.
The “Speak out” award to Lou Melgarejo, producer of the “Fixing” Autism video in honor of his daughter Bianca and the difficulties faced by families in gaining insurance coverage for needed therapies set the stage for the jam packed summit.
Utah Representative Merlynn Newbold and Professor Bonnie Mitchell from the S.J. Quinney College of Law, welcomed attendees prior to Lorri Unumb’s presentation,” Autism Insurance Reform Across America.” Five states that passed legislation since the previous Summit: Arkansas, Virginia, West Virginia, Rhode Island and California received honorable mention.
MI State Representative Jason Grill presented “Politics 101” relating lessons learned from his experience in the Missouri legislature’s passage of autism insurance reform.
Bryan Davey, PhD, BCBA-D (AZ) and Colleen Allen, PhD, CCC/SLP (MI); employer representatives Doug Green of DTE Energy (MI) and Jeremy Shane of HealthCentral(MD) and parent advocate Karen Fessel, Dr. PH(CA) presented “Convincing Self-Funded Companies to Add an Autism Benefit.”
Misty Bloom, JD of the Behavior Analyst Certification Board(FL); Andrea Chait, PhD, BCBA-D, NCSP (RI), and Jill McLaury, MS BCBA (WV) gave an overview of the provider credentialing issues.
I joined attorneys Ele Hamburger (WA), Dan Unumb (SC) and Dave Honigman (MI) for an update on litigation efforts against insurers.
Billy Edwards, MS, BCBA (TX); Mike Wasmer (KS), and Amy Weinstock (MA) shared their experiences implementing autism insurance laws in their respective states.
Adam Cole, JD, General Counsel, CA Department of Insurance; and Angela Nelson, Director of Consumer Affairs, and Melissa Palmer, Legislative Director, from the MI Department of Insurance and Jacqueline Eckert, MedClaims Liaison (PA) discussed “Enforcement of Coverage”.
A mock legislative hearing on autism insurance reform, provided an opportunity for attendees to experience first-hand the challenges frequently experienced by advocates.
Insights by the Autism Speaks Government Relations team specific to grassroots development, communications, policy, implementation and enforcement was interspersed throughout the summit.
As all of us headed back home to different parts of the country, colleagues, old and new shared smiles and hugs of encouragement. Once again, the connection of hope and ideas has been sparked and 2012 is destined to be another year of hard-fought progress in the effort to ensure access to autism insurance coverage, family-by-family, plan-by-plan and state-by-state.
Many thanks to all the families and advocates who packed the hearing room yesterday, dressed in red and carrying pictures of their children or accompanied with their children.
Our hearing was well orchastrated. Lorri Unumb(Autism Speaks Senior Policy Advisor), Dr’s Bryan King and Gary Stobbe (Seattle Children’s Hospital Autism Center), Kathy George (Harrison, Benis & Spence attorney), Arzu Forough (Washington Autism Alliance & Advocacy) and Chanel Krueger (highly accomplished, articulate young lady with autism) were among those who provided testimony is support of Shayan’s Law, Autism Insurance Parity (AIP). (The hearing can be viewed through TVW archives by clicking here).
The fiscal calculations on the state of WA to cover the public employee’s dependents was grossly inflated ($141,773,139), so much so that several committee members requested a revised fiscal data from the office of Financial Management (OFM).
The Senate committee members were clearly in favor of Shayan’s Law. Our next steps is two fold, provide true cost impact data from states that have had AIP for over a decade AND to continue to build the momentum of support.
The House Human Services Committee examined the current strategies and best practices for diagnosis, availability and attainability of services for persons with autism on June 16th.
It was very clear that the members of the committee had heard from their constituents on the overwhelming unmet needs of your loved ones with autism.
Chairwoman Dickerson requested specific recommendations from the Department of Health member on the panel, who informed them none would be forthcoming. The paenl and Chairwoman Dickerson shared their disappointment with the Department of Health attorneys present for their lack of direction to the legislature on the legislative actions needed.
In attendance, Sue Elliott, Executive Director of the ARC of Washington, pledged her strong support to work with the Autism community towards addressing top priorities and needs in the 2011 legislative session.
Please see contact information for the committee members in attendance as well as contact information for Sue Elliott, Executive Director of the ARC of Washington. Please take a couple of minutes to write to the Representatives as well as Ms. Elliott for thier interest in helping prepare WA to face autism more effectively.